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EL-10-21-2614 , � ���� �� � � ������������ �� �, �� �� ��� � � ` ��` , ; ,�� . � �� Miami Sh��es Vill��� �����������������������; � � � >. �*���� sot�so N�z�,� �� ;; � ���� �� � ��� � � ��> >: ��'� > : ; ��`����';����r ,�������`` < , Miami Shores FI.33138 � � " � " ;� ..R ��„� 305-795-2204 � � �#?���'���������k���`: , �f�,�.;,�` « :: z : ;:<.,::�,. ��..,.. ��42�{tS�'� o .., � � � ��� �����'����� EXpir��ic�n: oA�/26/z�2z � � �� � ��� � �� �.sr.. Lacation Address �arce0(Vearv�b�r E �_��_�.a���_�� ,�,� _�_...k_� �__e�� .. ._.... n �_._ . n�... ���� . �aa� �...... �„_. , ��6�rv�l��e�s�r, t�ia�►�snar�sF F€.s�ss� ��zzszo�za2oa � �...� . . � .� c��,���cs M.a�....����_ ���_w_ww._w�.mv.�__��_ . __ e._w__._ � �._..��.w......_.__r�_a_m�_�_ _a.�.. ��_. _ �w��w�..w..,..,.�....�... �___Mw_�_d�__.��w�..�_�_m�.��.._.�� NECTQR IONDQNO C3wner AI.L PNASE ENTERPRiSES ��ntractor � 1665 NE 1C14 ST IAZARO FERRlAND�Z Mame:7�62Q85518 SANCNEZME48�a YAHQO.COM �025 SW 26 ST SRNCNEZNiE48 c�r YAHOO.GO�r1 .��. ,-��_�.._.�_.�.m�_ �__�.......,_...�_�� �.�._,_�....����_�___ _.,._,.,.�,� rr�� � .,w.,_._. ....._.�.�u.____._,_____.___., ° !ns eettan R� uests � Deseript�on:ftEPAiR METEft FP� �� V�luatian: $ 5E)0,00 � ���� �:.. ; ":'.:� . ,�.:�.���.. ....., , � .:,:.,:: , � T�talSq Feet: Q.QO ��.,,. �r � Fees ,0.mount I�ayments Date Raid Amt Paid Applieatian Fee-�ther $50.00 T`Ota1 F��S $116.30 CCF $0.60 CaSh 1Q/22/2021 $yp,p� DBPR Fee $2.00 Credit Casd 10J26�2Q21 $66.39 I�CA Fee S2.QQ Education Surcharg� $p.�p �����t Due: $4.Q0 Permi�Fee $SO.OQ Seanning Fee $9.00 TechnofogyFee SZ•SQ T�tal: $516.3Q 1� 1 �1� In consider�ti�n of fih� issuance t� me of this permit, ! agr�e to pe�form the work eovered hereunder in compiiance with alI ordinances and eegui�tions p�rtaining thereto �nd in strict conformity with the plans, drawings, st�4ements or specifications submitted to the propee a�thorities of Miami Shares ViI(�ge. In accepting this p�rmit I assume eesponsibility fc�r al!work done by either mys�If, my ag�nt, servanfs, or empiayes. I unders4and that separat� permits ar�r�quired foe�LECT'RICAL, PLtJM�ING, (VIECN�NICA�,WINE}QWS, DOC}RS, FtQQFENG and SWIMMIN�POO�w�rk. .� � C7WNERS RFFIE} �`iT: I cert that all the c�egaing informatior� is accurate and that ail work wili b� dane in eampliance with ai! applicabie laws r�gula4ing constr c:€ien�nd ao ng. Futherm re (auth�rize the above named conte�aetor to da fhe wark stated. 1 � �- � RuYhorized S� na �._�m.. `�=: �... �Ei� ._._ _�_� ctQr l Agent Dste � � O�tober 26,2021 P��e 2 0$2 � (� {�� � },��1 (� � p � ���_��� 1 I � S I�� ���, '� �7 �. I � �� � °�; � } } � ' � . �� �`"IT , } � C; 1 ,� G ��' �� �4 � l �� � � ''` � � � �}��i 1 �}� ��� � �a w� z_.. 10050 N.E.2nd Avenue,Miami Shores, Florida 3313� ���� � Tef:(3Q5)795-22t�4 Fax:(305j 756-8972 �� tNSP�C'�IC3IV IENE PHQNE RIUfViBER:(305)762-�949 � �`� �'`�.�„� �� � Mast�r Permit N�. ��-: T� �� � x�`� � �-��' � �� �� (.� �� Sub Permit �lo, ��ur��i�� ���c���c � fto����v� � �Evis�o� � Ex�rE�sio�v �����w�� ❑P����i�v� � ��e��r�Fca� ❑�ua��e w��Ks ❑ c����� �F � ca�cEC�a-r�oN ❑ s�c�� CQNTRACTOR DRAWlNGS F ; ���� 1Q�AQDRESS: ' �°'_,�� � �. ��,...;_ t` .,.� �`� �..µ., .. Citv: Miami Shores Cauntv: Miami Dade Zip: FoliojParcel#e .��P ��.��' � �'��'� �� �� Is the Buildin�Histaric�lty Designat�d:Yes NO C}ecupancy Type: �oad: Canstructian Type: Flood Zone: BFE: FF�: t � � _ � . Y 2 .��. ���,i Fa � �� � �. OWNEEi:Name(Fee Simple Tifleholder): �� � i ����'� � �_ '�����'`' ��� �`� Phone#: �� ` � � �` ` ��" `�' � ' � � �.� Address: � ` -,�� �`,' �:� �`���a,��'.`� � f,, � , � Gity: � ` 0 , ��t����y t � �'��'���� � SCate: ��� Zip: ����' ° �``�� Tenant/�essee Name: Phone#: _ ` . ,�� Er�aiL• �� �C���� ����� � �`���e ,���;`� ��' ���� '�€ � _-� ��.� ���� r � e � � _n C�NTRAC�'OR:Company Name:�������.�� `�� � : �.��.�, e�r,�� � ..!', �„ Phone# �<�i, . M� � �. ;� "3 ��,�� � � Address � � {. ..�. �` i• ��� � ,�_�, ,°� City: �.� a �� � State:� ��=r' Zip: .�'� �� t � �. ...,. � Qualifier[Vame: .�� �� � �' `'� � � � � �� �1� � u�m �• Phone# ";��'' �, �� �.� .�, �.� � State Certificat�an or Registration#: � ��:.k- _� ���t� s� ���� �� Certificate of Campetency#: �ESlGRIEft:ArchiteetJEngineer: Phone#: Address: City: Sta[e: Zip: Value af Work for thts Permit:$ ���� SquareJLinear Foata�e of Work: Type of Wark; ❑ Addition ❑ Alteration ❑ Rlew � Repairjfteplace ❑ Demolition C}�scription of Work: ��, �� � ��� �`�°��`.��� ��� �� �'�'��°° Spec�fy color vf�c�lar thru �i�e: SubmEttal Fee$ Perrrtit F�e$ GCF$ CQjCC$ Scanning Fee$ Radan F�e$ DBPR$ Natary$ Technolagy Fee$ Training/Edu�atian F�e$ Double Fee$ Structural Reviews$ Bond$ TC}TAl fEE NqW QUE$ �� � �C� (Revised02J24j2014) �onding Company's Name{if applicable} Banding Company's Address _ City S�ate Zip Mortgag�Lender's Name(if applieabfe} Martgage l.ender's Rddress City State Zip Application is hereby made to obtain a permit ta do the work and installations as indicated. 1 certify that no work or installati�n has commeneed prior ta the issuance of a permit and that all vrork will be performed to meet the standards of all laws re�ulating canstruction in this jurisdictian. I understand that a separate permit must be secured far EGECTRIC, PIUEVi�ING, SIGNS, PC}QLS, FURNACES, BQILERS, HEATERS,TANKS,AIR CONDITIONERS, ETC..... QWNER'S �FFIt�AVIT: 1 certify that al! Ehe fore�oing informatian is aeeurate and that all wark will be done in compliance with all applicable laws re�ulating canstruetion and zoning, " ARRiIN� T� QWNE�a Y�UR FAILURE T� RECORD A Nt?TICE QF COMMENCEMENT MAY RESUCT IN YaUR PAYING TWI�E FQR iMPR�VEMEN`fS T'A YQUR PROPER . IF Y�U INTEND T� Q�TAIIV FINANCING, CONSULT WITH YOUR LENDER tJR ,�N A O�RIEY BEFQRE ���IJRDING Y�l1R Nt7TI�E OF C�MMEN�EMENT." Notice ca Applreant: As a canditian to the issuance af a burtding permit wrth can estimated value exceeding$2500, the apptictrnt must pramise in good faith ihc�t a cvqy of the notice af cor»rrteneement and construetic�n lien !aw brc�chure will be delivered to the person whose property fs subject to attachrrrent. A(sca,a certif+ed�opy of the recorded notice�af cor»rrreneement mus[be posted czt the jab site far the first inspection which oecurs seven (7J dvys after.the bcailding permit is issued. in the absence of sueh posted notice, the inspecfr`on vurtt not be approued and a reir�s��ction fee� ` be eharged. � �� :�/`� �'` �,� ���.� ,� Si�nature � Signatuee CONTRACTOR The foregoing ins°trument was acknowledged before me this The faregaing instrument was acknawledged before me this � day of ��� "����-�` , 2Q �'� , I�y �`� d�y of �-`�--m .-� , ..� ,�� � , bY ��.�`��� ���"l���1°� ,�uho is persQna!(y known to �� ��� ���'��"1�����ti�o is personally known to m�c�r who has produced ��- � �'� �--- as me or who as .�� �a����r����c���,s��r�� identificatian an tir� � tak��6�1�.�€��°t�� identifieati a�` di���r#'�E�� Lili�n��P,I��r�� p t�y�c��r�,rzn r��a t��3t� NATARY PU�L! . �� t�y C s�mrv,ias�cm wk�o�3t�s NOTARY P I��e.� ��p"�s t92ra5t2t�25 �, ���� �xp�r�s f}�Ii 5t2Ct25 i , i �� � � a� � , � Si�n: & Sign: Print: � � � � �� <'1 �.� � ���ld�°� f"`f.'. � Print: �°1�C��"1 e�, �'`�, e��s.,��' -�-�,. � Seal: Seal: �,�� ���ry�U��,c����� f. ,�� �.�*�� ,a�4�ry�ut�l�e����e, �t€i,�t��tu�Atu�f�g . Le#t��v��-�t�:���� �� . �� ftAy C�rntnis��crn . ���'� -� , � �y�� Keee�F�x,�2�t � ��,,�� �.<�,�re�t32��f,t?+i?5 � �aea ��� ���t5=.�,�„a � � ���x����:*�;*�* * * ***��*�*�x***�**�***� � * ��:��w�� *���**�x* �, `� APPROVED BY ��� � � ���..�Flans Examiner Zoning Structural Review Clerk (RevisedQ2/24J2014� Prop�rty Search Applie�tion - Miami-I��de Count}j Fage 1 c�f l ����. �t� �� �� � . � � ��� � � ������`�� � � �� � � �� ��1CT1CYI�C�/ ���C>� �ener�t�;d On: t4112f2021 Pro��rty Er�fc�rmation . ,.�� � � _ °° �,' V Folica; ;11�2232-032-0200 � ��`� � � _ �.� _ --.-�_ �1&65 N� 164 ST _ .__ , � ; �w�',, ;� Prapea�fy Addr���: €Miami Shores,FL 3313�-2667 _�_��_.�.�,� �,_�.��.__�..� �.._.� __ O�vrner ff�ECTOR LONDONO jMf�RIA SANCHEZ _ . _ w_...�_.,_m_m�._._.__�___�__ ,_� �_.A_�..__.�__._.___.�___�...___.w_._.__.. __._ [1�ailing�ddress €1666 NE 104 ST � �' �� � ' �r, ,� �MIAM(SHORES, F�33138 USA �''� ���,� : __ � � _ ._�.__._�__ � __m___ �..__ , PA Rr6mae�r,�c�ne OQ SGL FAMI�Y-28Q1-3QOQ SQ .����� ��._��_.��_ ._ � F�, �. _.._�n�______�. �_._�_.��.��� ��__�a.�_. �rimary t�andUse �61�1 RESIDENTiAL-SlNG�E :; � � i�AMILY: 1 UNIT ; Beds!�ath�f Natf �mm��� ;2/2(U___.�. e.�.�________� �.��� ����_.__.____..._______._� �.__m n, Flaors___ .__m��. � � � � __�� _ ?� Living li�it� E� �, ��.. � _ �.�.a A�tu�Il�rea ;3,962 Sq.Ft � �e�� ` ' �Pving Ar�a � ?1,9��Sq.Ff .�.�.�_.�.�. � �� � __.._��._._...� _�_____._.� _._.____.._..._.._...._.._.._�.._._.._....�.. ._ Taxa�l�V�lue Informatior� Adj�sted�tc�� ;2,3�2 Sq.Ft � �. ����� � 2Q21; 2020i 2Q19 �.QtSize €8,440 Sq.Ft � _�___ �_�__ _e�__ __. .��a_ � �n _�i____.____.� ___ YearEtuilt �� ���.954 � Gounty , ________ _.__h_n. � ._.__ . ��._ Ex�*mption Value �w50,QOd $50 000� �50,000 � . ...... � _�___._____.___ __ __._ _ Ass��smen#Inf�rt�ation Taxable Value ! $�27,600i $833,644� $83�,TQ4 � _�___ .___�____�._�...� __._.�__�_��w__u_�. z_ ._...._r_...�..�_ Year 2021 2020� �019 Schoof�oard _.�._ _ __ _ _._ _��� _ � ___�. _. _�___ _ ,—�.__ .__��_.�_.�m_______-.- __�____ I�and Va6ue j $449,150� �449,15d; �449,15Q �xemp4ion Value I �25,QOOi $25,QOQ $25,OOd __. � __-____w__��.�� �_ __r �.k. ��._. .�f___.._.,�____ � � _ �..____.. _.._.�.r.._._...�_.._...._ .. � �_ _______..�.__ _, r �utldEng V�lu� € $425,1�7i �430 1$9� �43�,191 T�xabl�V�Eue � $�52,64t�; ��5�,644� $863,704 �_���__m��,.�..�_ �..� m�m��M��_ _����__ �__�._ m__.____�...n _._.__________._.�_.._�._.._..._.�. � �._�__t .___...� ��e XF Value � �3 263� $4 3051 $4 363 Gity+ _._________.___..________..�.___ ___. _.. , __.__..�____.__._. ��� �_�m ��_mm__ �..._mm�_�_�. � �� � _._�_� � ��� .��.�.. ltRark�t Va1u� $�77,600j �8�3,644 $888,7Q4 Exempti�an Value i $50 OdO, $50,40Q� �50.00� �� _ __�_ . �__��_.� ����. � _ww�.__ � ___� �_.__ �.�,.____._�__._ T�x�b(eVaiue i $827,6Q0; �833,644� $�3�,704 �_�__.�� � � � Asst�$s�dYaEue � �877,600= $$83,644� �$�$,704 , I ��_���_��.__�.�.� m _ �_.�_ Regic�nal _._.v_.�.�..v._.__ ._.�_m____� �-a- ;--___.�___...__.._;___._.�_,.�_.�_ �en�fits Op�fo atian Exemption V�lue � �50,oQ0� $50,(3Q0� �5Q,QOa ��nefit �Type � 2021 2020� 2Q19 Taxabl�V�lue _��� _�827,60fl; �833,64����$�3�,70A �.� �_' � ___.__�.__� �.��_m� Horrt�st��d �mptio� �25,000� �25.Q00� �2�,Q4� �__�__�.�__�_._�_�________���_ra_____.__� � ._.e_A__�__. ._��.__.. S�les Infe�rm�ticrn Second Hom��t�ad i�xempti�n ` �25 000, $25,006 $25 Of�O , � _ � ____�_.��_.�_. ___.�,_.... �. _� .._� ��_� _�_ J ._ ___. , Note: Not ali benefits ar��ppiicable to alE Taxable Vaiu�s(i.e.Gaunty, Pr�viaus Sale ! Price; OR�o�k-Page � Qualification Description .��.�..._. Sch�ol�oard,Gity, R�giona!). Q7t1(}12Q18 � �1,125,000� 31075-3000 �Quai by�xar�r of deed _,m____._____.__..�____. 0519312008�= $�54,000� 26619-1779 Sal�s which�re quaiifi�d Short�eg�l Description --�-�---���- ----� _� �_�_ �ae_� .�_ 0910112(303 ; �520,000� 21645-2693 Sal�s whieh are qualified RIVER�AY PR(�K AC7C�N P�40-72 LOT 21 BL{�3 LOT SIZE IE�R�CU�AR GOG 21645-2693 Q9 2003 4 The Office af Ehe Property Appraiser is continually editing and updafing the tax roll.This wet�site may not reflect the mast eurrent inPoemafipn on record_The Peaperty Appraiser and�Fliami-Dade County assum�s no liak�ility,see full disctaimer and User Agreement at http:!/www.miamidade.geaviinfo/disciaimer.asp Version: lzttp�:Ilu=ww.miamid�d�.�ov�A�pstPAlprc�pert��se�-ch/ � I(l/12/20�1 � '�� ��``�= Ron DeSantis,Governar Naisey S�shears,Secretary ��� ���Y* r � �: �� - __�� a � �;��� � ���"; ! �� 4 T � � 1 ���`����'� �* PART E F' I 5 A PR � ��#�'}i�,A►L � 1 � E�E�T 1� L T CT �10E �1 � � TNE ��E�TRICAI. GC��ITRACTC}R NEREIN 1S CERTIFIED Ui�C3ER TNE PRC��tISI(��S �3F �:NAPTER 4�9, FI..C�F�IC�A STAT'tJTES Additiean�l Busir��ss Qu�li�ic�tic�n � AL.� F'�-{�►5E EPJT`E[�PRiSES II�C 3�22 �W 1bTN ST Ml,4f�il FL 3�145 � LICE�J�E U �E�; EC13C1t�9723 �KPIRAdT1+C� �A�'E; /�U��JST �1, 2022 Always verify I�censes or�line �t �yFlc�ridaLicense,cc�m ■ � ' ■ � �'r'� , C�c� nvt �It�r th�s dc��urr�ent in ar�y fc�rm. � � �;'° This is your licer�se. It is unlawf�al fQr anyc�ne c�th�r th�n th� licensee to use this document. ■ �� q �;s ___._____._________.___.____.____��_ � N � � �11��me—D�d�; Cc�s�re�y, St�te� caf Fl���d� -�r�a�sss r�o�r���t�v-r�o r�o�r Px�v ' � ; 72�f3272 ���___ � i ____.:- tz�a��a�ssr� €tu�r.tat� �tr,to�rrso. ���� �� ����r��sc������e��s�s�r�� ������v�� SEP�"� � 3flp 2�22 � 3�23 SV1i 3 6�"N S� 75'c3f3Q�2 P�u�,s#re e!i=,�>��yesl at�I���oi�aisin�ss Pt111AN11 FL 3i1�� Pur.s�3ar,�to C;;,ur�ty Code � ���'�"��� f'si���4e�k3,�1—Art 9&i0 ��� is��� d�,,�°� [�c'k�' r��aed€sz s�r;_rvr��or ausi�rrss � Al� PHCaSE E�v�TEt2PR!S�S l"a� 19� E3 ECTR1�'�i_�Oi�ST�?t�C�T�tJF? �'Arnw�raraE{;�rvF� � FER,�'A"J�EZIs�.?�C7Q�1t��IF1ER E:�.�30�9723 rrrAx��,it�crr�rs ���.a� ��Jo�;'2c�2� V�1c�rk€�r{s; 1 C�ECK2l-2]--fl74693 ih[s Looa7 Bus"aness Tux fiea»ip2 only cor�#�rms p�ymeni of ths l.�cal��2aistes�7ax.Th�a f4ecai�tt is nn4 a ficesns€�. �ermit.or�ce�i"sf"sc.ak3on c,4 tite hnld�,r s qu�Iifice#ir�r�s,io drs busiz»ss. Ncsidor musi comp3y v�4tt�any gouem�naasY�l t�r nongo�rsrn��n4�1 re�gulatorp iz��us�ad a�t�uirem�nts u�rtfsets apply to 41ke busiet��s. Ttra SiECE?PT htQ,a4wva must ba Gisplapsd on aII�rrmm�rcf:s!v�fiicl�s-Pr�iarr�i-Dad�Cade Sec�a-Z76_ �s�rmr,�r�infarmaticrra,uasi£wwy r»�amida�#�gov�,jtaxG911�r4ar '.. .�� i2 � � . G�t�TIFIGAT � F L.1�4 I�ITY lN �U A �E °�'�`��`°°"��" 1 Q1p512Q21 THIS GERTIFICATE I5 lSSUE�AS t�MEATT�R C3F iNFQRft+IATtON t?NLY AND GCINFERS NO RfGHTS UPQN TFE�C�RTEFIGATE HQ�DER.THI� CER`fIFICAT�Dt?ES NC?T AFFIRtt�ATlV�LY OR NEGATIVE�Y AMEND,EXTEN�CIR,AL7ER TH�CQVE G�AFF(}R�ED BY TNE Pt?GiGlES BE�OW. THtS CERTtFICAT�OF IN3U�ANCE DQES NOT CONSTITUTE A G�N7RACT BETVYEEN TN�tS�U#NG iNSl1RER(S),AE�TNORE2E0 REPRESENTAT6VE OR Fi20�UCER,AND THE GERTf�IGATE HC)LDER. IMPORTANT: If the certificate holder fs an ADDtTIONAE.INSURE[�,the palicy{ies}must have ADDITlONAL INSURED provisians or be endorsed. If SUBF2C?GATIC}N 18 WAIY�D,subject to the terms and conditions of the poticy,ceetain policies m�y require an endarsement. A stat�ment on th�s certificat�does not eonf�r right�t�the eerEifleate holder in Iieu af such endorsement{s)� n�ooueeR c rvTncr Georgina Bianca NAME: CaSUalty�ySt@IT15,InC. PffONE (305)551-Q69Q FAX (305)551-Q857 /C o xt: A/C No: 3331 SW 1d7Ave E-�ai� eor ina casuaif s s4ems.com ACIDRESS: 9 g � Y y lNSURER(S}AF�ORDING COV�RAG� � NAIG# Miami F� 33185 ��SURE��, Granada lnsurance Company INSURED INSURER B; Ail Phase Enterprise Ina iNsuRetz c: 3021 SW 16th ST i�suReR o: INSURER E: MIAMI FG 33145 INSURER F: CQVEi2AGES CERT"IFIGATE NUMBER: ��.Za102306644 REVISI4N NUMBER: THIS IS TO CERTIFY THAT THE PQ�ICIES OF INSURRNCE LISTED 6ELOW FiAVE BEEN ISSUED TQ THE iNSURED NAM1IiEC}ABC7VE FQR THE PO�ICY PERIdD WDiCATED. NOTWITNSTANpWG ANY REQUIREMENT,TERM OR GQNQfTION OF ANY CQNTRACT QR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEQ OR A�AY PERTAIN,THE iNSURANGE AFFORDED BY THE PO�ICIES QESCRlBEQ HEREIN IS SUBJEGT TO ALL THE TERMS, EXC�USIQNS AND CONQITIONS QF SUCH PQ�ICIES.LIMITS SHOWhi MAY NAVE BEEN REDUCED BY PAID C�AIMS. ���'R TYPE QF Ih1SURANCE POIICY EFF POGECY EXP LTR IP! D WVD POUCYNUMBEI2 MMlDDlYYYY R9M/DDlYYYY LIMITS � COMPAERGiAl.GENERALLIABII.Ifl EAGHpCCURRENCE � �.000,000 " Too,aoo CLAIM&MADE �C�GCUR PREhhISES tEa acc�rrence S � MEa EXP(An one personl $ S�Q�� A 01�5F�00146955 9012412020 1Q12�412021 PERSON��&�DviN�uRY S �,OQ0,000 GEN'IAGGREGATEUMITAPRLiESPER�. GENERALAGGREGATE � �,d40,Q00 � PQL€CY �PR4- � � 2,OOd,00Q JEGT �C PRqQUCTS-COMPr6PAGG $ t}iHER � AUTOMOBI�E l.IABIUTY COM8INED SINGLE�IMlT � -�a accident � ANYAUTO 60pilYINJURY(PerRersonj S ._..___._..._.............. OWNEQ SCFiEDULED �QDILY lNJURY(Per accident) S AUTQS ON�Y AUTOS _,,,� HIRED NON-OWNE6 PROPERTY QAMAGE � AUTQS ON�Y AUTOS ONLY Per�ocident S UMBRELLA LIAB aCCUR EAGN OGCURRENCE S EXGESS�tAF3 CUiiMS-flAADE riGGREGATE S .� . DED RETEtiT!QN S S WORKERS COPAPENSATiQN PER OTM- AND EMPlOYERS'�IA6EGITY Y r N STRTUTE ER ANY PRORRIETQft?PARTNERtEXECU'fIVE � �j� E.�.E.ACH RCCIC1ENi � QFFICER'MEM�ER EXCLUQE6? °'�' (Mandatory in NHj E.�..piSEABE-EA EMP�OYEE 5 If yes.descrlbe under DESGRIPTIQN 6F OPERATtONS belQw E�.C)IS6ASE-POUCY LIMIT $ DESCRIPTIQN OF OPERATIONS t LQCATION5 t VEHIG�ES (ACORD 105,Additional Remarks ScheduEe,may be attached if more space is r�quirad} C�de 02478 IEEeetrica!Work insidelautside bldg LiC.EC 13d09723 CEi2TIFiCATE HQLDER CANCELLATIQN SHOULD ANY 9F THE A�t?VE DESCFti�ED POCICIES BE CANCE�LED�EFORE THE EXPIRATION DATE THEREOF,MOTECE WILL BE DELIVERED IN Miami Shores Viliage AGCORDANCE WITH TtiE POUCY PROVISIONS. 1Q�5Q NE 2ndAve. AUTHQREZED REPRESENTATIVE Miami Shor�s FL 33138 Q 19�$-2Q15 ACORD CORPORATiON. Ail rights res�roed. ACQRD 25(2016t03) The AGORD name and Iogo are registered marks of ACQRD , , � "'-��� �� � ���� � . � �� � �+�-'' ��. �� J4�1tv1Y P�.TRONIS GHIEF FINRNCIAI.OF��C�F? a�'��'T'�C)F F�.��fL�l� C��F'#�F�Tk�I��lT C��F11���i�1�.L���Vf��� C�61�t�lt�t� t�F 1tVC}��C�f2�'�����N�AT°lC3N *���Rl"IFt�AT��F �L.�CTI��! TCJ�� �X�iVIPT F�t�IVI FI�C?RIC}A WC?�K�Ft�° ��l�I�ENSAT'6t�N L.�W** C�f��T�UG�`IC�N lN�U�1"R�° �X����'IC?PI This cerfiifies that the individua! IisEeci below h��elected ta be�xempt fram�Ic�rida Wc�ekers'Cc�mp�ns�tic�n I�w. EFF�C�'IVE C�t�T�: 7/27/2C}2(J E?C�tRA1"6AN ��T'�: TJ27f2Q22 P���C?N; �A�ARO F�RNA�lDEZ EP�A(!�: JNQRTAF'La��EI�LSt�t�TH.NE�i' F�tN: 383927QT6 �USiNEB�N�IM�APl�ADDF2�S5: AL.L Ph{d��E ENTERPRISE� INC 302�SW 16`�H ST fVl{RMI, F�.33145 SCC3E��f)F Bl1SIN�SS�R�'RAC��: ESectrieai Wiriny Within 0uiidings ar�d€3eiver� IMRORTANT:Pursu�nt ta sut�section 4Af�.E�S{i A),F.S.,an o(fi�csr'af a coeporatiof�who r�i�cts exarngtion Fram this chapker by filing a certificate af eEecfion ucidee this section may�Q[r�covec b�ne6ts ae com�ensat[on unde€ihis chapter.Pur�u�nt ta aubsection 440,Q5(12�,F,S.,Ceetificatea aP efectian to be exempt iss��ed under subsection(3)shall app{y or�fy to the corpprate o�c�r namecf on the notice of ek�ction tQ b�ex�mpt and aA�IY cznfy within the scape Q€ti�e business a€ irac��liaked on the nafic�o�eleeFian to be exen�pt.Pursuant Eo subseetion 44f�_Q5{13),F.S.,nokic�s oP electi�n to i��exempE�nc#e��tificates o�electian to b� �x�mpf shafi be subject ko revocatian i€,at�ny tinl�after the iiling oi the��otiee or the issuanee of the eerti�cate,the persc�n nam�:ct on th�nc�tice ar c�rtiFi�ate no Ionger m�ets the requiraments o�this sectia€�for issuanee e�f a certificade.The de�aartn��nt aha�[revake a Gertificate at any time€car iailur�af€he persan named on th�certificate ta meet the requirements o�t1�is saetio€t. [��S-F2-G�WE;-25�GERTkFIGATE C��EE�CTtC?N TQ�E E�C�hlIPT�tEVfSEa C18-13 EQ12Q1310 C�U�STlC}NS`I(85Q�413-1609 ��� �t��es,� ��r����is�s ��.�:,: 30,?1' SW 1f.`'`' S,t (\!Ii�ar��i, F� 3�1�5; Zo/�z12a2�. stafi� of Florida Caunty �f �Vliami Qade Bef�re me this day personally appear�d l.azaro Fernandez who, b�ing duly sworn, depases and s�ys: That he or sh� is will be th� c�nly pers�n workin� c�n th� projeet located at: 1665 NE 10� Stre�t, Miami She�res FL 33��� C�ntractc�r Sigr�ature �1�, Sworn te� (or �ffirmed) �nd subscribed before m� thi day c�f � , 2Q21 �y �,�� �1�� � ���,r���c�c��r� . . Ldli�ra�t+��l�a�r�x r. b � �y G� �t4ht�93994 �e� Expt 02t95t�425 P2CSOt1d0�tf Kt1CJW Or produced identification Typ� of Iden�ific�tion Prod�aced � ' t��O��,S ��� � � iami hore� illage .��� ���.�� 1� 1 �'� ��� 100�o N.E.�►,a a���,�� ����4�� Miami Shores, Florida 33138 Tel: (305} 795.2204 F�x: {305} 756.8972 otice to wn r � rker ' en tion Insur nce e ti n t l<.�2 ,Z � t t.�. � i lt., \ ti ��.t t :".�v �� �;. { ` ��t t,.. �Z 1. � �1�� •tt }�\ i i�� Z tit � j � \`, �� .}��� i ti\ 6t :\� 1\ti �l �lt �i����� l 1.� � { a\:� '., „t,.'��,�. .�r, ct..,�����,., ,� ,�5�� ..,,1i£ �a 1� .:1�� t ���1�a �,�is�.E\„ A„ .t,. Florida Law reqt�ires Worlcers' Compensation insurance eovera�e c�nder Chapter 440 of tl�e Floi7da Statutes, Fia. Stat. � �40.05 allows co��porate afficers in �he constructian i��dust�-y to exempt tl�emselves fram this reqUiren�ent fo�-at�y constr�etion prajeet p3-ior to obtaii�it�g a building permit. Purstzant to tl�e Florida Divisian of Workers' C�Tnpensation Employer Faets l3rocl�ure: A�� employer ir� t1�e eot�st�-uetic�t� industry �ilio emplo}�s one or more part-tiz��e or full-time employees, i�lelE�dinQ the o�vner,must obtain wc�rkers' compensatio�i eoti=erage. Corparate offiee�-s a�- memt�ers of a li�nited li�b�lfty cotr�}�any (LLC} in the const�-uction industiy may elect ta l�e EX�ITl�?t If: 1. Tl�e officet•awns at least 10 percent of the stock c�f the eotporation, ar it� the case of an LLC, a staeetneut attestinb to ttle ininimum l 0 pereent a�vnershi�; 2. The officer is listed as an offieer of the corporation in the records af the Florida C3epartmenE of St�te, Divisi€�n of Cotporations;and 3. Ti1e cc�rparatian is registel•ed and listed as acti�=e �uitl� tlte Florida Departme��t of State, Division of Coipai-ations. Nc� more than tt�ree coiporate officers �aer eorporatic�n or limited liability eor��any n�ei�lbers are �Ilo�ved ea be cxempt, Construetion exeil�ptions are vaiid for a �aeriod af two years or untit a ��alutlta�-y re��ocat�on is tiied or the exemption is�-e�Toked by t}�e Divisiot�. Youf-cant�-actor is requestin�a�er�xlit under this�varkei-s' cotnpeflsatiot� exemption and l�as aeks�o�vled�e that l�e c�r slie will not use day labor,�art-tinze employees or si�bec�ntractars for��our prc�ject. Tl�e cay�tractor has�rovided an aftidavit stat3ng that he or s}�e ti�ill �e ti�e anly person allo�ved to wark on you�-project. In these eircutnstal�ces,Miami Shores ti'�Ilage does not requi�•e veri�cation af wot•kers' compensation insurance coverage from t}�e cant�-actor°s eompany for day labor,part-titne er��pioyees or subcc�tttraetors. BY SfGNING �ELQVa� YQLT A�KNOVJLEDGE THAT YQU IIAVE READ TNIS NOTICE .AND C'�DERSTAND ITS CCINTENTS. �`? `, � ,/f � '� l� f Signature: `'� �- ue __�— ���.'�--� State of Florida Cotiiity of Mia�ni-Dade � Tl�e foregoing�ras ackt�owledge before tr�e€�vs � � day°of � � � ��`�-�� �20 �-� I3y���::-�:.���. ��'��-�.�.� � '�"��'��`�-������l�o is�ersonally k��a�u��to zne or l�as produeed `�� ��w l?.: �,�`�_�����`��` asidetitif�cation. - Y-�z -�-" .� �' �^ 1�iOC11y �";,.` � `""' ' �� �`_C_. ����'��4-�`� ������`��,�, SEAL: ,_ ��` "�Q� �,� */ :' '���: i:�;. �t_y�.��.'� ;*= fviy., `����I�A '=i .���.�'�.�.�g �„a��d CV � �s,o`.�� �'..��Ott���f��`S•� 't'�����3 ., �d T/yu ��tvrn� $�?,� ��''"`����'�`Aub1ic r`�,2p�� —� ���'+�'riter� ♦�►��'�a�'� �" � i�mi h�res illag� �:... ���.� II � ``� - �� �ao�o N.�.2►,a �V�►,�,� �`���`�c►� Mi�rrii �hor�s, Florida 3313$ T��: (�o�) �s�.2�o� Faa�e (3Q5) 756.�972 tic t r — r r ' ti In r c ti Fiorida Law reqt�ires Warkers' Compensatic�n insurance coverage u�zder Chapter 44Q af the Fiorida Statutes. Fla. Stat. § 44Q.QS allaws corpe�rate affic�rs in the eanstnzction industry ta �xempt themselves frazn this requiren2ent for any canstru�tion projeot prior to o�taining a building permit. Pursuant ta the Flarida Division af Workers'Compensation Empioycr FacGs Srachure: iAn �mployer in the �onsEruction industry who �mplays ane or more partntir��e ar fuli-time employ�es, ineluding the€�wner,rnust obtain workers' eampensat3on coverage. Corporate c�fficers ar memb�rs of a limited Iiability company (LL,C} in the eanstrnctian iudustry �nay el�ct to be exetnpti£ 1. The officer owns at least 10 pereent of the stack of the carporation, or in the case of an LLC,a statement attesting to the minimum 1 Q perc�nt ownership; 2. The affc�r is listed as an afficer c�f the corporation in the records af the Florida ( Department of State,Divislon of C'orporations,and 3. The cc�rparation is regisYered and listed as actiue with the Florida I)epartment af State,L�ivisr`on of Corporations. � I No �nore than three corparate officers per carparatian Qr Iimi�ed liabiliry coin�any meml��rs are i aliaw�d Eo be exetr�pt. Construction exemptions are valid F�r a period of two ye�rs c�r until a valuntary revocatian is fil�d or th�exemption is revokec�by the Division. Yaur contractar is rec�uesting a permit ttnder this warkers' �ompensatioa exemption and has acknowl�dg�that h�ar she wiil nat us� day labar,�art�time�mployees or subcontractors for yacu-praject The contractor has provided an affidavit stating that he or she will be the only person allawed to work on yc�ur proj�ct_Iz�these eircumstances,Miazni Shores Villag�daes not require verifieatican of warkers' compensatian i�asuranc;e coverage fram the contractar's company for day labar,part-time ernpl�yees or suhcontractars. BY SIGNING BELC}W YOU ACKN WI.ED�E THA`T YC3U HAVE READ THIS N�TIC� AItiID UNDEIiSTAND ITS C(?NTENTS. i � Signaaare: Stat�af Flarida Caunty of Mia�i-Dad� The forego'tng was acknowledge before me this �� day of�__C���"�-� ,20�. By_��-�,( ��°1�„��� who is personaliy knawn to me or has produced as identification. Notary � SEAL: c�,y�u��c�s������ 1. +P e Lofi�n�A9,Qlv�tez " �_ MX G��xatv��s��NFi 093t�Q Ex{S�r��42t9512Q25 � � � °��°_ , ��` o �� � � �-�...� �_ � F t 2(�4� ��P �..,��..w � , �� � � �� '�. � � � ` � $ ��4 �t � � O � �� ` �' � � f`�� � �� � � ; f'"� �, � F �r^ € � �'i .,.�. � � ��c„°"` a a - � p �, €4.& ��1� C� � � w" s ° e & �. ���`l.' � � i"`` , `� � .�`� ��� f ct; a�.. ��"� _� � p � �3 �s ?� � �' � ' � ��� ulc&c�'t� � � �� r;, ��� � � �,1 e-a �„-�. i g,� � � � �' �S a � � � � t�i 0 ��(�„� �b�`�� :s`J � �r^- a.„. , s . . , �, � � � E � � "���.�i �#�i6't,4. 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